Over the past three-to-five years, there has been an increase in women choosing to undergo bilateral mastectomies — even women who have low-risk, early-stage breast cancer and who traditionally would be treated with a lumpectomy, or breast conservation therapy.
University of Michigan plastic and reconstructive surgeon Adeyiza O. Momoh, M.D., has been studying this phenomenon.
“Patients are really scared about having cancer come back or having cancer in the other breast, and they want to do everything they can to eliminate that possibility,” says Momoh, who is also a clinical assistant professor of surgery. “The reality is that having both breasts taken off, especially in low-risk patients, really doesn’t change the risk for recurrence very much. But they ultimately take on the risk of additional surgical complications by getting the other breast taken off. The other reason many opt for having both breasts taken off has to do with trying to achieve symmetry. The average patient will think if you can reconstruct one breast, then reconstructing two breasts at the same time will get the best result, while the truth is we can get great symmetry even with a unilateral mastectomy.”
Momoh specializes in microsurgical breast reconstruction — also called perforator flap reconstruction — a technique that uses a patient’s own tissue, rather than an implant, to reconstruct the breast. With this technique, Momoh harvests skin, fatty tissue and blood vessels from the patient’s abdomen (DIEP flap), buttocks (GAP flap) or thighs (TUG and PAP flap), moves it to an area on the chest and puts the vessels together under a microscope so the tissue can live in its new location.
“It’s the closest we can get to a natural appearing and natural feeling breast reconstruction,” Momoh says. “That is important, especially in patients who are undergoing unilateral breast reconstruction and will have a natural breast on the other side. Our goal is to restore the shape and form of the breast as close to the natural breast as possible, so using patients’ own tissue allows us to do that better than an implant would.”
Other advantages to microsurgical reconstruction include less maintenance over time. Reconstruction is typically a series of operations, but once you get to a final result with microsurgical breast reconstruction, there’s rarely a need for additional operations in the future. As the woman ages or gains weight, the reconstructed breast will age and grow in a similar fashion. If a woman has an implant reconstruction and they live with it for many decades, odds are they would require additional maintenance operations in the future because of things like implant rupture or scar tissue that forms around the implant. Additionally, patients who get the DIEP flap surgery, where tissue is taken from the abdomen, are often happy with its slimming affects.
However, there are trade-offs with a complicated procedure like microsurgical reconstruction.
“You’re dealing with a longer, more complex operation at the onset which means you’re in the operating room under anesthesia for a longer period of time and you’re in the hospital for a few more days. Because you’re recovering from two surgical sites, the recovery might be a little bit longer than it would if you had an implant placed.”
Momoh also stresses that what works for one patient might not work for another and what makes one woman happy may not do the same for another. In providing reconstructive services to patients who have been diagnosed with breast cancer, he says it’s important to make sure women know all of their reconstructive options — from implants to microsurgery. Women who have access to treatment at a multidisciplinary setting like the U-M — with medical, radiation and surgical oncologists, and plastic surgeons all in the same space — have the benefit of knowing and discussing their options for reconstruction upon diagnosis and throughout treatment.
“Historically, mastectomies were kind of separate from reconstruction,” Momoh says. “Women would have a mastectomy, have their chemotherapy and radiation, and then in the future start to think about reconstruction. But these days, reconstruction surgeons are part of the team that tries to put together a plan for the patient’s care right from the get-go. From the time of their diagnosis, we are available and have consults with patients to discuss reconstruction. I think that makes it easier for patients to decide on cancer treatment and think about reconstruction at the same time.”
Through his current research, Momoh aims to advance breast reconstruction options by focusing on how to get the best results for patients who have had radiation therapy treatment. He has found that natural tissue breast reconstruction typically provides the best results because the perforator flaps are able to withstand the effects of radiation on soft tissue if performed at the right time. Traditionally that operation takes place months after radiation, but Momoh is investigating the possibilities of performing immediate reconstruction, followed by the radiation treatments without negatively affecting the results.
Momoh hopes that research like his, as well as continued patient education efforts, will help stem the tide of women choosing unnecessarily aggressive bilateral mastectomies.
“As a reconstructive surgeon, I feel it’s important for women to have a choice in what is done for their mastectomies and ultimately their reconstruction, but we want to make sure that patients are making educated decisions,” Momoh says. “We want patients to know they can rely on their physicians for information regarding their specific cancer. We are up-to-date on the literature, on the studies and where things are with cancer care. We understand some of the finer details that differentiate one form of cancer from another, and we can provide them with enough information that would allow them to make those well-educated decisions.”